Jean M. Cox-Ganser

Metalworking fluid‐associated hypersensitivity pneumonitis: A workshop summary

A workshop discussing eight clusters of hypersensitivity pneumonitis in the automotive industry among metalworking fluid-exposed workers concluded that a risk exists for this granulomatous lung disease where water-based fluids are used and unusual microbial contaminants predominate. Strong candidates for microbial etiology are nontuberculous mycobacteria and fungi. Cases of hypersensitivity pneumonitis occur among cases with other work-related respiratory symptoms and chest diseases. Reversibility of disease has occurred in many cases with exposure cessation, allowing return to work to jobs without metalworking fluid exposures or, in some situations, to jobs without the same metalworking fluid exposures. Cases have been recognized with metalworking fluid exposures generally less than 0.5 mg/m3. The workshop participants identified knowledge gaps regarding risk factors, exposure-response relationships, intervention efficacy, and natural history, as well as surveillance needs to define the extent of the problem in this industry. In the absence of answers to these questions, guidance for prevention is necessarily limited.

Hydrophilic Fungi and Ergosterol Associated with Respiratory Illness in a Water-Damaged Building

Background Damp building–related respiratory illnesses are an important public health issue. Objective We compared three respiratory case groups defined by questionnaire responses [200 respiratory cases, 123 of the respiratory cases who met the epidemiologic asthma definition, and 49 of the epidemiologic asthma cases who had current physician-diagnosed asthma with post-occupancy onset] to a comparison group of 152 asymptomatic employees in an office building with a history of water damage. Methods We analyzed dust samples collected from floors and chairs of 323 cases and comparisons for culturable fungi, ergosterol, endotoxin, and cat and dog allergens. We examined associations of total fungi, hydrophilic fungi (requiring water activity ≥ 0.9), and ergosterol with the health outcomes using logistic regression models. Results In models adjusted for demographics, respiratory illnesses showed significant linear exposure–response relationships to total culturable fungi [interquartile range odds ratios (IQR-OR) = 1.37–1.72], hydrophilic fungi (IQR-OR = 1.45–2.19), and ergosterol (IQR-OR = 1.54–1.60) in floor and chair dusts. Of three outcomes analyzed, current asthma with postoccupancy physician diagnosis was most strongly associated with exposure to hydrophilic fungi in models adjusted for ergosterol, endotoxin, and demographics (IQR-OR = 2.09 for floor and 1.79 for chair dusts). Ergosterol levels in floor dust were significantly associated with epidemiologic asthma independent of culturable fungi (IQR-OR = 1.54–1.55). Conclusions Our findings extend the 2004 conclusions of the Institute of Medicine [Human health effects associated with damp indoor environments. In: Damp Indoor Spaces and Health. Washington DC:National Academies Press, 183–269] by showing that mold levels in dust were associated with new-onset asthma in this damp indoor environment. Hydrophilic fungi and ergosterol as measures of fungal biomass may have promise as markers of risk of building-related respiratory diseases in damp indoor environments.

Respiratory morbidity in office workers in a water-damaged building

We conducted a study on building-related respiratory disease and associated social impact in an office building with water incursions in the northeastern United States. An initial questionnaire had 67% participation (888/1,327). Compared with the U.S. adult population, prevalence ratios were 2.2–2.5 for wheezing, lifetime asthma, and current asthma, 3.3 for adult-onset asthma, and 3.4 for symptoms improving away from work (p < 0.05). Two-thirds (66/103) of the adult-onset asthma arose after occupancy, with an incidence rate of 1.9/1,000 person-years before building occupancy and 14.5/1,000 person-years after building occupancy. We conducted a second survey on 140 respiratory cases, 63 subjects with fewer symptoms, and 44 comparison subjects. Health-related quality of life decreased with increasing severity of respiratory symptoms and in those with work-related symptoms. Symptom status was not associated with job satisfaction or how often jobs required hard work. Respiratory health problems accounted for one-third of sick leave, and respiratory cases with work-related symptoms had more respiratory sick days than those without work-related symptoms (9.4 vs. 2.4 days/year; p < 0.01). Abnormal lung function and/or breathing medication use was found in 67% of respiratory cases, in 38% of participants with fewer symptoms, and in 11% of the comparison group (p < 0.01), with similar results in never-smokers. Postoccupancy-onset asthma was associated with less atopy than preoccupancy-onset asthma. Occupancy of the water-damaged building was associated with onset and exacerbation of respiratory conditions, confirmed by objective medical tests. The morbidity and lost work time burdened both employees and employers.

Acute Upper and Lower Respiratory Effects in Wildland Firefighters

Objectives: To assess acute respiratory effects experienced by wildland firefighters. Methods: We studied two Interagency Hotshot Crews with questionnaires, spirometry, and measurement of albumin, eosinophilic cationic protein (ECP), and myeloperoxidase (MPO) as indicators of inflammation in sputum and nasal lavage fluid. Assessments were made preseason, postfire, and postseason. Results: Fifty-eight members of the two crews had at least two assessments. Mean upper and lower respiratory symptom scores were higher postfire compared to preseason (P < 0.001). The mean forced expiratory volume in 1 second was lower postfire compared to preseason (P < 0.001) and then recovered by postseason. Individual increases in sputum and nasal ECP and MPO from preseason to postfire were all significantly associated with postfire respiratory symptom scores. Conclusions: Wildland firefighting was associated with upper and lower respiratory symptoms and reduced forced expiratory volume in 1 second. Within individuals, symptoms were associated with increased ECP and MPO in sputum and nasal lavage fluid. The long-term respiratory health impact of wildland firefighting, especially over multiple fire seasons, remains an important concern.

Sarcoidosis, asthma, and asthma‐like symptoms among occupants of a historically water‐damaged office building

UNLABELLED Sarcoidosis is a granulomatous disease of unknown etiology with evidence of association with exposure to microbial agents. In June 2006, we investigated a sarcoidosis cluster among office workers in a water-damaged building. In the course of the investigation, we became aware of a high rate of respiratory complaints including asthma and asthma-like symptoms. We conducted case finding for physician-diagnosed sarcoidosis and asthma and administered a health questionnaire survey and pulmonary function tests (PFTs) to consenting occupants. We compared prevalence ratios (PRs) to the Environmental Protection Agencys Building Assessment Survey and Evaluation study (BASE) and the National Health and Nutrition Examination Survey (NHANES). We identified six sarcoidosis cases. The current building prevalence is 2206 cases/100,000 population, elevated, compared with the US population range of <1-40 cases/100,000. Of current occupants, 77% (105) participated in the health questionnaire survey and 64% (87) in PFTs. Physician-diagnosed asthma was elevated, compared with the US adult population. Adult asthma incidence was 3.3/1000 person-years during the period before building occupancy and 11.5/1000 person-years during the period after building occupancy. Comparisons with US office workers (BASE) yielded elevated PRs for shortness of breath [PR, 9.6; 95% confidence interval (CI), 6.1-15.2], wheeze (PR, 9.1; 95% CI 5.6-14.6), and chest tightness (PR, 5.1; 95% CI 2.8-9.0). PFT results supported reports of respiratory symptoms and diagnoses. Based on our findings building occupants were relocated. PRACTICAL IMPLICATIONS The remission of occupational asthma caused by certain known antigens improves with early diagnosis and removal from exposure. As a suspected antigen-mediated disease, sarcoidosis might also benefit if affected persons are isolated from continued exposure. Our investigation identified a high prevalence of new-onset sarcoidosis, and asthma among workers of a water damaged building with a history of indoor environmental quality complaints. Removal of all individuals from such environments until completion of building diagnostics, environmental sampling and complete remediation is a prudent measure when feasible.

Asthma and respiratory symptoms in hospital workers related to dampness and biological contaminants.

UNLABELLED The National Institute for Occupational Safety and Health investigated respiratory symptoms and asthma in relation to damp indoor environments in employees of two hospitals. A cluster of six work-related asthma cases from one hospital department, whose symptoms arose during a time of significant water incursions, led us to conduct a survey of respiratory health in 1171/1834 employees working in the sentinel cases hospital and a nearby hospital without known indoor environmental concerns. We carried out observational assessment of dampness, air, chair, and floor dust sampling for biological contaminants, and investigation of exposure-response associations for about 500 participants. Many participants with post-hire onset asthma reported diagnosis dates in a period of water incursions and renovations. Post-hire asthma and work-related lower respiratory symptoms were positively associated with the dampness score. Work-related lower respiratory symptoms showed monotonically increasing odds ratios with ergosterol, a marker of fungal biomass. Other fungal and bacterial indices, particle counts, cat allergen and latex allergen were associated with respiratory symptoms. Our data imply new-onset of asthma in relation to water damage, and indicate that work-related respiratory symptoms in hospital workers may be associated with diverse biological contaminants. PRACTICAL IMPLICATIONS In healthcare facilities with indoor dampness and microbial contamination, possible associations between such conditions and respiratory health effects should be considered. Good building maintenance and housekeeping procedures should lead to improvements in employee respiratory health.

Identification of Mold and Dampness-Associated Respiratory Morbidity in 2 Schools: Comparison of Questionnaire Survey Responses to National Data

BACKGROUND Dampness and mold problems are frequently encountered in schools. Approximately one third of US public schools require extensive repairs or need at least 1 building replaced. This study illustrates how national data can be used to identify building-related health risks in school employees and students. METHODS School employees (n = 309) in 2 elementary schools (schools A and B) with dampness and mold problems completed standardized questionnaires. Responses were compared with participant responses from the 3rd National Health and Nutrition Examination Survey and were indirectly standardized for gender, age, smoking status, and (for school B) race. Uncontrolled comparisons were made to responses from a study of office workers, as well as between responses from school employees in different sections of the school buildings designated by decade of construction. RESULTS Employees from both schools had excess work-related throat and lower respiratory symptoms, as well as eye, nasal, sinus, and wheezing symptoms. School B employees also had excess physician-diagnosed asthma and work-related fatigue, headache, and skin irritation. Employees in sections of the school buildings that were categorized as having greater dampness and mold contamination had more frequent upper and lower respiratory symptoms than employees working in other building sections. CONCLUSIONS This noncostly type of analysis of indoor air quality complaints can be used to motivate and prioritize building remediation in public schools where funds for building remediation are usually limited.

Respiratory inflammatory responses among occupants of a water-damaged office building.

UNLABELLED The National Institute for Occupational Safety and Health (NIOSH) received a request for evaluation of a water-damaged office building which housed approximately 1300 employees. Workers reported respiratory conditions that they perceived to be building related. We hypothesized that these symptoms were associated with airways inflammation. To test this hypothesis, we assessed airways inflammation in employees using exhaled breath condensate (EBC) and the fraction of exhaled nitric oxide (FENO). In September 2001, a health questionnaire was offered to all employees. Based on this questionnaire, NIOSH invited 356 symptomatic and asymptomatic employees to participate in a medical survey. In June 2002, these employees were offered questionnaire, spirometry, methacholine challenge test, allergen skin prick testing, EBC and FENO. FENO or EBC were completed by 239 participants. As smoking is highly related to the measurements that we used in this study, we included only the 207 current non-smokers in the analyses. EBC interleukin-8 (IL-8) levels, but not nitrite, were significantly higher among workers with respiratory symptoms and in the physician-diagnosed asthmatic group. Of the analyses assessed, EBC IL-8 showed the most significant relationship with a number of symptoms and physician-diagnosed asthma. PRACTICAL IMPLICATIONS Implementation of exhaled breath condensate and exhaled nitric oxide in indoor air quality problems.

Health effects of exposure to water-damaged New Orleans homes six months after Hurricanes Katrina and Rita.

OBJECTIVES We investigated the relation between respiratory symptoms and exposure to water-damaged homes and the effect of respirator use in posthurricane New Orleans, Louisiana. METHODS We randomly selected 600 residential sites and then interviewed 1 adult per site. We created an exposure variable, calculated upper respiratory symptom (URS) and lower respiratory symptom (LRS) scores, and defined exacerbation categories by the effect on symptoms of being inside water-damaged homes. We used multiple linear regression to model symptom scores (for all participants) and polytomous logistic regression to model exacerbation of symptoms when inside (for those participating in clean-up). RESULTS Of 553 participants (response rate = 92%), 372 (68%) had participated in clean-up; 233 (63%) of these used a respirator. Respiratory symptom scores increased linearly with exposure (P < .05 for trend). Disposable-respirator use was associated with lower odds of exacerbation of moderate or severe symptoms inside water-damaged homes for URS (odds ratio (OR) = .51; 95% confidence interval (CI) = 0.24, 1.09) and LRS (OR = 0.33; 95% CI = 0.13, 0.83). CONCLUSIONS Respiratory symptoms were positively associated with exposure to water-damaged homes, including exposure limited to being inside without participating in clean-up. Respirator use had a protective effect and should be considered when inside water-damaged homes regardless of activities undertaken.

Occupational sensitization to soy allergens in workers at a processing facility

Background Exposure to soy antigens has been associated with asthma in community outbreaks and in some workplaces. Recently, 135 soy flake processing workers (SPWs) in a Tennessee facility were evaluated for immune reactivity to soy. Allergic sensitization to soy was common and was five times more prevalent than in health care worker controls (HCWs) with no known soy exposure.